Negotiating the Trust Cliff
The high cost of low reliability in healthcare experiences
William R. England, Ph.D., Strategic Analyst, NRC Health
Michelle Silva, M.A., Strategic Advisor of Consumer Experience, NRC Health
Print Full ReportTrust is foundational to strong healthcare relationships, and reliability is one of its most critical drivers. This nSight explores how discrepancies between what consumers and patients expect and what they experience during care can damage trust—even for health systems with strong brands and reputations. NRC Health data shows that tight alignment between brand/marketing and patient experience is a strategic imperative.
Reliability: the (fragile) connection between expectation and experience
Reliability is a key driver of trust—it’s also a psychological contract built on the relationship between expectation and experience. Social science research supports this dynamic. According to Expectancy Violation Theory (Burgoon, 1993), when an experience falls short of expectations, individuals often interpret it as a breach of the social or relational contract, triggering emotional responses like disappointment, distrust, or even anger.
Similarly, Oliver’s Expectation-Disconfirmation Theory explains that satisfaction with an experience (and, by extension, trust) is directly influenced by the degree to which our experiences meet, exceed, or fall short of preexisting expectations. Studies have also shown that trust damaged by unmet expectations is difficult to repair, particularly in high-stakes industries like healthcare (Kim, Ferrin, and Rao, 2009).
It’s the classic bad vacation experience: the photos promised a weekend of luxury, but the hotel room was small, the pool murky, and the service lackluster. You paid for something exceptional; you got something forgettable. In most industries, you can laugh it off and leave a bad review. The difference is that bad experiences on vacation are disappointing and inconvenient. In healthcare though, when expectations aren’t met and experiences falter, the stakes aren’t just emotional—a bad experience in healthcare can be catastrophic.
Experiences matching expectations is foundational to trust
Consumer and patient expectations are especially high-stakes, because people are at their most vulnerable when it comes to addressing their physical and mental health, often within the context of quality of life and even death. A broken promise by a health system or provider can feel more personal than with other consumer experiences. The violation doesn’t just create disappointment; it also creates doubt. That doubt may in turn become a lens through which future interactions are viewed. Reliability—the ability of an organization to consistently deliver on what it promises—then becomes the inflection point between expectation and experience.
Reliability is the inflection point between expectation and experience.
When NRC Health’s inpatient, hospital-level data on image/reputation (i.e., brand perception) and actual patient experiences are analyzed together, and then trust scores are factored in, four distinct patterns emerge.
As shown in the quadrant analysis below, hospitals’ image/reputation scores were plotted along the horizontal axis, and patient experience scores (likelihood to recommend a facility) along the vertical—and a post hoc analysis of trust scores revealed that each quadrant contains facilities with a distinct trust profile:
The Trust Landscape: Your Brand Image and The Experiences You Deliver Shape Trust
- Upper Right: The Gold Standard – The ideal: patients arrive with high expectations and their experiences validate them. Average Trust = 74.3%
- Upper Left: The Pleasant Surprise – A marketing opportunity: unexpectedly strong experiences can build loyalty, even in the absence of a strong image/reputation. Average Trust = 72.6%
- Lower Left: Low Expectations Met – Demands investment: organizations here must improve experience and (re)build perception simultaneously. Average Trust = 69.1%.
- Lower Right: The Trust Cliff – The most dangerous: high expectations, unmet, lead to the highest levels of distrust. This is where patient disengagement and reputational damage are most likely. Average Trust = 66.2%.
This framework is not just descriptive. Like previous research, it confirms that trust isn’t built on brand alone; it’s earned and kept through the delivery of consistent and reliable experiences. It offers a strategic lens for evaluating how healthcare organizations are perceived, what kinds of experiences they deliver, and where they might be vulnerable in terms of eroding trust. It also highlights the paradox that a strong brand can become a liability if an organization sets expectations that frontline experiences fail to meet. Below is a simplified view for interpreting these key findings:
Each quadrant carries different strategic implications: when brand perception is plotted against likelihood to recommend scores, and trust scores are subsequently factored in by quadrant, what emerges is a framework that offers leaders a diagnostic tool to identify where their hospitals stand and how they should (re)act.
Connecting expectation with experience
Below are suggestions for health systems to strengthen the fragile connection between expectations and experiences:
The bottom line: image/reputation alone are not enough
More than just a tagline, your brand promise encapsulates your system’s values and purpose. It is a statement of what your system stands for and what consumers and patients should expect from you. Put simply, the expectation you set in the market is your experience commitment, and the experiences you deliver are the expression of your brand promise.
In an era of increasing choice, coherence between brand promises and reality can be a key differentiator. Healthcare consumers—especially younger, digitally savvy generations—compare experiences across industries. But the real risk? Consumers and patients don’t always voice their unmet expectations—they often quietly disengage, stop listening, stop coming back, and start telling others about their bad experiences.
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Suggested citation for this report:
NRC Health. 2025. Negotiating the Trust Cliff. https://go.nrchealth.com/nSight/july-2025 (Accessed mm/dd/yyyy).
© NRC Health 2025
Burgoon, J. K. (1993). “Interpersonal Expectations, Expectancy Violations, and Emotional Communication.” Journal of Language and Social Psychology.
Oliver, R. L. (1980). “A Cognitive Model of the Antecedents and Consequences of Satisfaction Decisions.” Journal of Marketing Research.
Kim, P. H., Ferrin, D. L., and Rao, H. (2009). “Trust Repair After an Organization-Level Failure.” Academy of Management Review, 34(1), 85–104.